MEDICARE: SUMMIT DENTAL CENTER, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN0014412	FL

General Provider Information

NPI Number	:	1255410742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMIT DENTAL CENTER, PA

Provider Business Mailing Address
First Line	:	3913 N ANDREWS AVE
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309-5239
Country	:	US
Telephone Number	:	954-561-6675
Fax Number	:	954-630-2017

Provider Business Practice Location Address
First Line	:	3913 N ANDREWS AVE
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309-5239
Country	:	US
Telephone Number	:	954-561-6675
Fax Number	:	954-630-2017

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JEAN R ELYSEE
Credential	:	DDS
Telephone Number	:	954-561-6675

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	02/06/2008

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